Provider Demographics
NPI:1215144936
Name:AMG-CROCKETT, LLC
Entity type:Organization
Organization Name:AMG-CROCKETT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIVISION PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONE
Authorized Official - Middle Name:LAW
Authorized Official - Last Name:KOFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-565-1506
Mailing Address - Street 1:PO BOX 847
Mailing Address - Street 2:US HIGHWAY 43 SOUTH
Mailing Address - City:LAWRENCEBURG
Mailing Address - State:TN
Mailing Address - Zip Code:38464-0847
Mailing Address - Country:US
Mailing Address - Phone:931-762-6571
Mailing Address - Fax:931-766-3339
Practice Address - Street 1:US HIGHWAY 43 SOUTH
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464
Practice Address - Country:US
Practice Address - Phone:931-762-6571
Practice Address - Fax:931-766-3339
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty